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Quels impact de l'hépatopathie sous jacente? - Dr Andrea Laurenzi

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Quels impact de l'hépatopathie sous jacente? - Journées de Chirurgie 2016

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Quels impact de l'hépatopathie sous jacente? - Dr Andrea Laurenzi

  1. 1. Quel impact de l’hépatopathie sous-jacente sur l’insuffisance hépatique post-operatoire Andrea Laurenzi - Daniel Cherqui
  2. 2. Hépatopathie • Cirrhose • Chimiothérapie • Cholestase
  3. 3. Hépatopathie • Cirrhose • Chimiothérapie • Cholestase
  4. 4. Operative risk and underlying liver 1023 liver resections (1990-2008) 22 7,9 3,7 1,5 27 8,8 8,5 3,7 0 5 10 15 20 25 30 Transfusions <2000 Transfusions >2000 Mortality <2000 Mortality >2000 % Cirrhosis No Liver Disease Cherqui unpublished data
  5. 5. 0 Cx Gr 1 Gr 2 Gr 3A Gr 3B Gr 4 Gr 5 MAJOR Rx 6 1 8 4 2 2 0 MINOR Rx 22 3 8 1 3 0 0 Liver Resection for HCC Paul Brousse Hospital 2013 - 2015 95 Patients 28 Laparoscopic Cirrhosis 57 Fibrosis 15 NASH 14 Normal 9 Mortality 2 Morbidity 40%
  6. 6. • Preoperative: patient selection – Liver functional reserve – Planning by imaging – Portal vein embolization • Intraoperative – Reduction of hemorrhage – Parenchymal preservation – Coelioscopie • Postoperative – Postop care – Follow up Progress in Surgery for HCC
  7. 7. Cirrhose • Sélection • Management
  8. 8. Cirrhose • Sélection • Traitement
  9. 9. Sélection • CHILD score • MELD score • Vert d’Indocyanine • HTP (gradient P-S, plaquettes….) • Fibrose (biopsie, fibroscan) • Volumetrie
  10. 10. CHILD-PUGH • 2007-2013 • 1242 patients • 166 (13,4%) PHLF • Mortality 1% Wang, BJS 2016
  11. 11. MELD N Mortalité P Cucchetti, J Am Coll Surg 2006 Cucchetti, Liver Transpl 2006 Teh, J Gastrointest Surg 2005
  12. 12. MELD Cucchetti, Liver Transpl 2006 IHC postop
  13. 13. Makuuchi, Semin Surg Oncol 1993 Ascites None or controlled Not controlled ICGR15 Limited resection Enucleation Not indicated for hepatectomy Trisectorectomy bisectorectomy Left-sided hepatectomy Right-sided sectoriectomy Segmentectomy Limited resection Enucleation Normal 1.1 – 1.5 mg/dL 1.6 – 1.9 mg/dL > 2.0 mg/dL Total bilirubin level Normal 10% - 19% 30% - 39% > 40%20% - 29% Vert d’Indocyanine
  14. 14. Major impact of pre-operative platelet rate < 150.000 / mL 22% 6% Liver Failure: 11% Mortality : 9% 2011 Maithel, JACS 2011
  15. 15. Only hepatic venous pressure gradient > 10 mmHg was significant in multivariate analysis for decompensated cirrhosis after hepatectomy Risk factor in univariate analysis Bilirubin rate Urea rate Rate of platelet ICG Clearence Hepatic venous pressure gradiant, Décompensation de la cirrhose : Persistance d’une ascite à 3 mois Bruix, Gastro 1996
  16. 16. Cucchetti, J Hep 2016
  17. 17. Cucchetti, J Hep 2016
  18. 18. Child A / Sans HTP 56% 71% Child A / Avec HTP No early impact but lower longtime survival after resection of PHT
  19. 19. Capussotti, WJS 2011
  20. 20. Capussotti, WJS 2011 p=0,02 All patients Child A patients p=0,5
  21. 21. Cescon, Ann Surg 2012
  22. 22. > 16 kpA: Ascite and/or POLF Cescon, Ann Surg 2012
  23. 23. Truant, JACS 2007 • RLV-BWR was more relevant than RLV-TLV in predicting postoperative course after right trisectionectomy • Patients with an anticipated RLV < 0,5% of the body weight were at risk of hepatic dysfunction • No deaths in the group of patients with RLV/BWR >0,5%
  24. 24. Paradis, Hepatology 2009
  25. 25. Paradis, Hepatology 2009
  26. 26. Agrawal, HPB 2011 Pre-operative liver biopsy to detect NASH in order to: • Limit the extent of hepatic resection • Use the PVE to optimize the post-operative outcome • Aggressively treat the cardiovascular associated disease
  27. 27. Wakai, JGIS 2011 • 225 patients • 3 groups NAFLD – HCV – HBV • Morbidity 59% vs 31/28% p= 0,043 • Mortality 12% vs 0,7%/3,3% p= 0,016
  28. 28. Cirrhose • Sélection • Management
  29. 29. Farges, Ann Surg 2003
  30. 30. Farges, Ann Surg 2003 Bilirubine Prothrombin Time
  31. 31. Post-operative Liver failure: Post-operative mortality: - TACE + PVE 4% - TACE + PVE 0% - PVE only 12% - PVE only 3% Yoo, Ann Surg Oncol 2011
  32. 32. Optimal Technique • Reduce blood loss • Fluid restriction anesthesia • Precise technique • Intermittent Pringle Maneuver
  33. 33. T T Limited resection “wedge“ Anatomical resection Parenchymal preserving Anatomical Resection Planning of resection
  34. 34. Man, Ann Surg 1997
  35. 35. Man, Ann Surg 1997
  36. 36. Morise, JHBP Sc 2015
  37. 37. Cirrhose - Conclusions • Major hepatectomy (≥ 3 segments) – Child A – MELD <9 – No varices, platelets > 100 000, gradient <10 mmHg – Response to portal vein embolization for Right Hepatectomy – FLR ≥ 30-40%
  38. 38. Cirrhose - Conclusions • Major hepatectomy (≥ 3 segments) – Child A – No varices, platelets > 100 000, gradient <10 mmHg – Response to portal vein embolization – FLR ≥ 30-40% • Minor hepatectomy – Child A (B for tumorectomy) – grade 1-2 varices (laparoscopic)
  39. 39. Hépatopathie • Cirrhose • Chimiothérapie • Cholestase
  40. 40. SOS (Blue Liver): Steatoheapatitis (Yellow liver): Oxaliplatin Irinotecan Liver Toxicity
  41. 41. Khan JHBP Surg 2009
  42. 42. Rubbia-Brandt, Ann Oncol 2004 • 51% of patients who received pre-operative chemotherapy had sinusoidal dilatation • 25% perisinusoidal and venocclusive fibrosis • Developement correlated to the use of Oxaliplatine
  43. 43. Karoui, Ann Surg 2006
  44. 44. Karoui, Ann Surg 2006
  45. 45. Wicherts, Ann Surg Oncol 2011 15% of patients who received pre-operative chemotherapy Increased GGT and Bilirubine are predictors markers
  46. 46. Ribero, Cancer 2007 p = 0.006
  47. 47. Vauthey, JCO 2006
  48. 48. Kishi, Ann Surg Oncol 2010 Extended chemotherapy increases liver toxicity without improving the pathological response
  49. 49. YesNo PosthepatectomyPVP(mmHg) 22.5 mmHg 15 mmHg Liver failure « 50-50 » criteria Allard, Ann Surg 2013
  50. 50. De Graaf, J Nucl Med 2010 Cut-off 2,5%/min/m2 can predict the incidence of liver failure 3% vs 56%
  51. 51. Chimiothérapie - Conclusions • Attention aux lésions induites par la chimiothérapie (> 6 cycles) • Augmentation de la morbidité post-opératoire • Une augmentation des cycles n’augmente pas la réponse pathologique • Bevacizumab a un effet protecteur sur le développent de SOS
  52. 52. Hépatopathie • Cirrhose • Chimiothérapie • Cholestase
  53. 53. Cescon, Ann Surg 2009
  54. 54. Kawasaki, Ann Surg 2003 Morbidity related to biliary drainage 2,5% No post-operative liver failure
  55. 55. Seyama, Ann Surg 2003 Cholangitis 30% (initial period) 1 Tumor seeding (percuteneous) No post-operative liver failure
  56. 56. Grandadam, Ann Surg Oncol 2010 Mortality 10,5% in the group without optimization
  57. 57. Sugawara Surgery 2013 • 21% of cholangitis in patients with biliary drainage • 75% of positive bile cultures at the operation • No difference in postoperative morbidity and mortality in patients with and without biliary drainage
  58. 58. Takahashi, BJS 2010 • PTBD recurrence 5,9% • Survival in patients with PTBD poorer
  59. 59. Hirano, JHBP Sc 2014 P=0,004 • Tumor seeding on the of percutaneous drainage • Peritoneal recurrence in the percutaneous group • Better survival for endoscopic drainage
  60. 60. Noie, Surgery 2001 Selective group: • Increase of FLR >50% • Better ATP synthesis • Increased cytochrome P-450
  61. 61. • Hyperthrophy ratio and bilirubine clearance higher in SBD vs TBD Ishizawa, Am J Surg 2007
  62. 62. Iacono, Ann Surg 2013
  63. 63. Farges BJS 2013 • Biliary drainage does not affect mortality • Decrease the mortality rate after right sided hepatectomy • Increase mortality after left sided hepatectomy • Preoperative bilirubine > 50 mmol increases mortality
  64. 64. Farges BJS 2013
  65. 65. Cholestase - Conclusions • Optimisation du patient avant chirurgie • Drainage biliaire du foie restant par voie endoscopique • Traiter de façon systématique les patients avec prothèses biliaires avec antibiotiques à large spectre

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